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THE AMERICAN RED CROSS
18/1918
DEPARTMENT OF NURSING
etc.
ar
T
Application for Enrollment
me A 10 4 3
+
(To be filled out entirely in applicant's handwriting and each question answered fully)
141615
/
2. 1. Name Address of in applicant full, Street in full 11) 434- 42 Ligin Ctty
L
E
Bantelyn,
State
21
3. Date of birth
Place of birth
Brusklyn
or a/widow? Lingle
5. Have you any physical defects or tendency to constitutional or pulmonary trouble?
Year
early
=
2
4. Are you married, single
Are you a citizen of the United States?
no
a
Are you physically strong and healthy?
The
M
6. Name educational institutions attended before entering training school, stating number of years at each and from which
you were graduated
languages than High English do Ichort speak? of none Bhdy n.y
gadyaty
P.S.
136
of
manual
+
5
7.
What other you
student
C
8. Occupation before entering training school
of
9. From what hospital training school did you receive your diploma ?
ney Date of graduation City Hospital
City and state
3
June, 1918
T
10. Character of hospital: General?
Yes
Special?
Private?
S
12. 11. Did your training include obstetrics ? Jax Care of men ? 600 Children? Yes of Contagious course diseases 2 Yep
Daily average number of patients in hospital during training
13.
Name and address of superintendent of training school under whom you received training
Length Missi 1/2 apr
14. If your training as a nurse was received in more than one hospital, give name, spent in each
Coarlyn C. Jray, City Hopetal Blackwolks location Ja; and new time You
15. Of twhat nursing organizations are you a member
City Rosital 2yp. 1ml. - purposition - n.4 hospital Bhly Happital n.y 5 Rurnes' ms.
16. is affiliated with
Which, alumnae if any, assucation, the American Nurses thirsly Association? nig City Copy Ass, member.
Shel latter
17. Give name and address of secretary of at least one of these organizations - Miss Amanda
18.
Are Fifon you Harv a registered tophen nurse exam.m In Hospital what state Journmen Date of registration slip hw feet Number City
my
19. How and/where employed since graduation:
Give dates with months
Name and address of employers
change nure
City Hispetal
from march
until 1918 July
of
new yob City bleft.
public Chasetress
Primate dusty
hinefs n.y Country Creficiatory Reg.
Registryary Lt. my
(Specify for which of the following services you wish to be considered.)
20. War service, wherever needed
Just
When available
Legants 15 non 15th
Are you willing to take the oath of allegiance?
21. Instructor Elementary Hygiene
yes
3
22. Public Health Nursing
In Town and Country, Nursing Service -
or for War Service
3
23. Name and permanent address
434-42 of nearest relative. 21 Bafatelyn, toger y
mi
8
Date
Nor 3- 1918
Signature of Nurse
Eigability lignt
of
To the Committee:
This blank is to be sent to applicant with circular letter D. M. R. 7, together with Forms D. M. R. 2, 11, 29 and A. R.
C.
703. Application forms (except of a nurse desiring to enroll for the Town and Country Nursing Service) after approval
and endorsement by Local Committee, with credentials (Form 3 and 4), together with Forms 10, 11 and 29, should be for-
warded through the Director of the Bureau of Nursing in your Division to the Department of Nursing, American Red Cross,
Washington, D. C.
In case the application forms of a nurse desiring to enroll for the Town and Country Nursing Service are sent to the
Local Committee, instead of to Washington, as instructed, such forms should be forward at once to Washington by the
Local Committee, from whence credentials will be procured.
(SEE OTHER SIDE)
Page data
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- Type
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Document data
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- Type
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DTO data
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Context sent to Scholar
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"ocrText": "DMRT\nZ3\nTHE AMERICAN RED CROSS\n18/1918\nDEPARTMENT OF NURSING\netc.\nar\nT\nApplication for Enrollment\nme A 10 4 3\n+\n(To be filled out entirely in applicant's handwriting and each question answered fully)\n141615\n/\n2. 1. Name Address of in applicant full, Street in full 11) 434- 42 Ligin Ctty\nL\nE\nBantelyn,\nState\n21\n3. Date of birth\nPlace of birth\nBrusklyn\nor a/widow? Lingle\n5. Have you any physical defects or tendency to constitutional or pulmonary trouble?\nYear\nearly\n=\n2\n4. Are you married, single\nAre you a citizen of the United States?\nno\na\nAre you physically strong and healthy?\nThe\nM\n6. Name educational institutions attended before entering training school, stating number of years at each and from which\nyou were graduated\nlanguages than High English do Ichort speak? of none Bhdy n.y\ngadyaty\nP.S.\n136\nof\nmanual\n+\n5\n7.\nWhat other you\nstudent\nC\n8. Occupation before entering training school\nof\n9. From what hospital training school did you receive your diploma ?\nney Date of graduation City Hospital\nCity and state\n3\nJune, 1918\nT\n10. Character of hospital: General?\nYes\nSpecial?\nPrivate?\nS\n12. 11. Did your training include obstetrics ? Jax Care of men ? 600 Children? Yes of Contagious course diseases 2 Yep\nDaily average number of patients in hospital during training\n13.\nName and address of superintendent of training school under whom you received training\nLength Missi 1/2 apr\n14. If your training as a nurse was received in more than one hospital, give name, spent in each\nCoarlyn C. Jray, City Hopetal Blackwolks location Ja; and new time You\n15. Of twhat nursing organizations are you a member\nCity Rosital 2yp. 1ml. - purposition - n.4 hospital Bhly Happital n.y 5 Rurnes' ms.\n16. is affiliated with\nWhich, alumnae if any, assucation, the American Nurses thirsly Association? nig City Copy Ass, member.\nShel latter\n17. Give name and address of secretary of at least one of these organizations - Miss Amanda\n18.\nAre Fifon you Harv a registered tophen nurse exam.m In Hospital what state Journmen Date of registration slip hw feet Number City\nmy\n19. How and/where employed since graduation:\nGive dates with months\nName and address of employers\nchange nure\nCity Hispetal\nfrom march\nuntil 1918 July\nof\nnew yob City bleft.\npublic Chasetress\nPrimate dusty\nhinefs n.y Country Creficiatory Reg.\nRegistryary Lt. my\n(Specify for which of the following services you wish to be considered.)\n20. War service, wherever needed\nJust\nWhen available\nLegants 15 non 15th\nAre you willing to take the oath of allegiance?\n21. Instructor Elementary Hygiene\nyes\n3\n22. Public Health Nursing\nIn Town and Country, Nursing Service -\nor for War Service\n3\n23. Name and permanent address\n434-42 of nearest relative. 21 Bafatelyn, toger y\nmi\n8\nDate\nNor 3- 1918\nSignature of Nurse\nEigability lignt\nof\nTo the Committee:\nThis blank is to be sent to applicant with circular letter D. M. R. 7, together with Forms D. M. R. 2, 11, 29 and A. R.\nC.\n703. Application forms (except of a nurse desiring to enroll for the Town and Country Nursing Service) after approval\nand endorsement by Local Committee, with credentials (Form 3 and 4), together with Forms 10, 11 and 29, should be for-\nwarded through the Director of the Bureau of Nursing in your Division to the Department of Nursing, American Red Cross,\nWashington, D. C.\nIn case the application forms of a nurse desiring to enroll for the Town and Country Nursing Service are sent to the\nLocal Committee, instead of to Washington, as instructed, such forms should be forward at once to Washington by the\nLocal Committee, from whence credentials will be procured.\n(SEE OTHER SIDE)"
}